HS Activities Permission Slip 21-22

PARTICIPATING IN THE THEATRE PROGRAM

Thank you for taking the time to visit our site and fill out this form.

**Please note that if you participate in ANY other after-school activity you will need some of these forms so it would be advisable to make a copy of these forms.***

HERE IS WHAT YOU NEED

The following forms are online and need to be filled out. Remember there are THREE separate forms that must be submitted.

1. Field Trip/Activities Permission Form

Just to be safe and to make sure we are always covered so we require both the PCS form AND the athletic permission slip to be filled out.

2. High School Activities Participation Form

Yes, this is another permission slip, but it covers a few different items. This is necessary in case you get hurt or need medical attention for any reason.
Keep in mind this is primarily meant for athletics so don't get scared when you read it.
If you also play a sport, you've likely filled this out and turned it into your coach. Please fill this out online for us so we have it for our records. Thank you.

3. Media Release

We will publicize in any possible way that we can. Often times that means contacting a TV or radio station, a newspaper or putting something online. The media release allows us your permission to use your son or daughter when those times come up

4. Student Insurance

This is NOT included in this packet as it must be completed ONLINE
Go to the school insurance page on this site or to pcsb.org/studentaccidentinsurance
You can purchase whichever policy you’d like, but the least expensive one is fine.
Once it’s purchased, you’ll get an email confirmation. Save that confirmation a PDF or JPEG and upload it on the site.

Again, without these forms, a student CANNOT stay after school for ANY reason with ANY club or sport

HOME EDUCATED STUDENTS MUST BE ASSIGNED TO A SCHOOL THROUGH THE DISTRICT AND SHOW PROOF OF IMMUNIZATION

Participation in competitive athletics, including cheerleading, may result in severe injury, including paralysis, or even death. Improvements in equipment, medical treatment, and physical conditioning, as well as rule changes, have reduced these risks, but it is impossible to totally eliminate such occurrences from athletics.

STUDENT NAME *

As it appears on the birth certificate

GENDER

GRADE *

DATE OF BIRTH *

Date

Are you an administrative transfer?

Yes No

Birth Certificate *

Yes No

Residence of Parent or Legal Guardian *

Street Address

Street Address Line 2

City

Residence Since?

When did you move to this residence

Student Residence (if different from Parent/Guardian)

Street Address

Street Address Line 2

City

Date that student began living at this address

Date

Name(s) and Relationship of Person(s) student lives with if other than parent(s) or legal guardian

Name

Relationship

Students participating in voluntary extracurricular athletics and activities, as defined by Pinellas County School Board Policy 8760, must purchase the Mandatory Student Accident Insurance Insurance made available by the School District. Purchase of a student accident insurance policy for football covers football and all other sports and activities requiring mandatory student accident insurance. Purchase of a (non-football) student accident insurance policy covers all (non-football) school related sports and activities requiring mandatory student accident insurance. Insurance may be purchased on-line at http://www.pcsb.org site shortcuts PE, Athletics & Extracurricular Activities. Note: This is excess Insurance. It is provided to cover some of the out-of- pocket expenses associated with accidents. It is not intended to replace your primary medical insurance. Any other medical insurance policy will be expected to pay before this excess student accident insurance policy. Mandatory Football InsuranceMandatory Student Accident Insurance Date Purchased Date Purchased

Date Student Accident Insurance Purchased *

Date

Date Mandatory Football Insurance Purchased

Date

EMERGENCY MEDICAL TREATMENT PERMISSION AND INFORMATION

I hereby authorize the school to obtain, through a physician of its own choice, any emergency care that may become reasonably necessary for the student listed on this form in the course of school-sponsored athletics, activities, and travel. Payment of all charges incurred for medical treatment is guaranteed by me or the insurance company(s) providing primary and/or excess coverage for the above-named student. * Please see attached FHSAA Pre-participation Physical Evaluation Form for pertinent medical conditions *

Student Participation Permission

***** PARTICIPATION IN COMPETITIVE ATHLETICS CAN RESULT IN SERIOUS INJURY, EVEN DEATH*****

I hereby consent for the above-named student to represent his/her school in school-sponsored athletics and activities. I understand the potential risks and that severe injury, including paralysis, or even give death may occur. I hereby agree to waive, release and discharge the School and the Pinellas County School Board from any and all liability for any injury or illness of the above-named student (s), including or for of any nature which may result from participating in voluntary school-sponsored extracurricular athletics. I agree to indemnify and hold harmless the School and the Pinellas County School death, claims from Boardofnature claims including costs, expenses, and fees arising out of or as a result of the participant's actions during this activity. This permission includes team travel for local or out-of-town trips scheduled for the theatre department.

Student's Signature *

Clear

School attended last year

Signature of Parent/Guardian 1 *

Clear

Work/Cell Phone *

Home Phone

Relationship to the Student *

Date *

Date

Signature of Parent/Guardian 2

Clear

Work/Cell Phone

Home/Work Phone

Relationship to the Student

Date

If only one Parent/Guardian signature above, explain reason

The FHSAA web site, www.fhsaa.org and your school's Athletic Director can best explain student eligibility requirements. If you have any questions about eligibility, please make an appointment with your schools' Athletic Director before completing this form or trying out. Participation in extracurricular athletics and activities is a privilege and can be suspended or revoked by the school administration when deemed necessary.

List schools attended by above named student during:

9th grade

10th grade

11th grade

12th grade

To submit the form

Click the "Submit" button below
Remember it is NOT turned in until you hit the submit button!!
You MUST click the submit button! Once you hit submit you're done! No need to turn in a hard.
Don't forget though, you need to submit all THREE forms :)

View the completed PDF

Click the "Preview PDF" button below
Click Submit then on the next page click the "download completed PDF" button.
It is HIGHLY suggested that you download a copy of the completed PDF for your records.

PCS Form 4-1891-A (Rev. 4/20) Review Date 4/21

Pinellas County Schools